Expertise with integrity

Gambling on the BPE Chart

Would you buy a second-hand car without a test- drive?

Contrary to misplaced belief, the basic periodontal examination (BPE) chart cannot and should not be relied upon to determine treatment needs. It certainly should not take the place of a physical examination and a solid consideration of the patient’s history.

Relying purely on the BPE is as risky as putting your money down for a second-hand car based purely on its’ MOT – dismissing the importance of a test-drive, service history and the V5C registration document. Just like buying a car, you need to do your homework if you want to make a responsible, informed decision about a patient’s treatment.

It’s the squeaky wheel that gets the oil

Unfortunately for one dentist and defendant, this was not the view of one of the expert witnesses in his case. In a gross miscarriage of justice, the “expert” did a hit and run, leaving the dentist’s career in a burning wreck as he was named and shamed on the General Dental Council (GDC) website – even though the civil case against him would later be dropped based on the evidence my homework uncovered soon after.

The road-trip to hell

As is often true in these cases, it all started when the patient’s dentist of 10 years went on holiday. His unavailability meant the patient attended a new dentist, who informed her she had periodontal disease and frightened her half to death. So she began civil action for the costs of remedial periodontal treatment and formally complained to the GDC.

Planning the journey: the method and the madness

I, too, was instructed as an expert witness on his case as a specialist in periodontics. However, my role and my methods were very different from the first expert witness. He was appointed by the GDC, who specifically instructed him to report on whether

or not a fitness to practice issue had occurred. Significantly, they restricted him to basing his report purely on the claimant’s dental records, as provided by the defendant. This included BPE chart indices over many years.

The solicitors acting on behalf of the claimant then instructed me to report on the claimant’s current condition, prognosis and future treatment requirements. I was to base this on my examination of the patient. But I didn’t stop there. Based on the experience of my near-40 years of practice, I have developed my own protocol. So I requested the patient’s dental records from her previous and her new dentist, as well as her GP’s medical records.

Pulling out the dental records: BPE indices

The dental records provided by her former dentist began with two occasions of bitewing x-rays taken approximately four years apart. Most entries included “examination S and P”, which I attributed to a clinical examination and the narrative for oral hygiene instruction and scaling.

In her last four years of attendance, the patient’s BPE charting stood at 333/333, indicating early to moderate loss of periodontal attachment. She was referred to the hygienist for two sessions of oral hygiene instruction and scaling consistent with appropriate measures.

Six months later her BPE chart recorded 223/323, indicating some improvement. I read that the patient was encouraged to focus on her interdental cleaning and arrangements made for a six-month appointment, when the BPE recorded was 222/222. Again, the patient was referred for a routine review in another six months.

Fiddling the figures: what the GDC saw

My fellow expert witness on the case was an experienced general dental practitioner with 35 years of clinical experience of general practice. His report focused specifically on the BPE charting, pointing out that any record of three or more indicated the further need of clinical parameters of pocket charting, bleeding and plaque indices. He reported that it was not credible that a chart of 333/333 could dip to 222/222, as the bone shown on the x-rays clearly showed further loss of crestal bone with the two sets of bitewing x-rays.

The GDC committee took a dim view of this and accused the practitioner of fiddling the numbers to put himself in a more favourable light. The GDC followed up the dentist’s public humiliation by placing a warning on the GDC website advising all third parties to warn the public of this professional miscreant. You can imagine the impact of this on his career and, I should imagine, his personal life.

Great news for the claimant though, as her solicitors licked their lips and proceeded with civil action. Her case was referred to the indemnity insurers, who appointed the services of another general practitioner who, again, did not examine the claimant.

Picture the scene

The BPE chart is proposed by the British Society of Periodontology to indicate treatment needs. Well, of course, it doesn’t. As a specialist in periodontics, I have many patients who have been referred to me exhibiting deep pocketing, multiple bleeding points and advanced bone loss. At presentation their BPE charts would be 444/444 or more. At subsequent visits and following my well established non-surgical treatment regime, the pockets reduce as tissues become tight, bleeding points drop off a cliff and the plaque control becomes meticulous.

Naturally, this doesn’t regenerate alveolar bone. Some sites may even show further bone loss. In the presence of gum recession and/or re-establishment of a long junctional epithelial reattachment with pocket reductions, I consider the situation is improving and would congratulate the patient.

The dirty air of the BPE

The story, however, appears quite different if you rely purely on BPE charts. If I were to use a BPE charting system, the scenario I’ve just described could well indicate readings of 1-2 at each sextant even though serial x-rays could show further deterioration. If a patient demonstrates 6mm recession in the absence of bleeding, the patient’s treatment needs become 0 and not at the previous level of 3-4. If previous pockets were at seven millimetres and then became pocket-less, the patient would rate a zero. A BPE chart, however, would have read a misleading four.

The GDC’s off-roading

In my opinion, this was not understood by the GDC committee nor by the expert advising them. It is also clear to me that their Expert did not know the difference between treatment needs and the periodontal history of attachment loss. In addition, none of the parties were aware of the systemic factors that could effect a rapid acute disease activity state that was only apparent in her medical records.

Lifting the bonnet: the examination and medical records

Chronic depression over 20 years was just the beginning of the painful but helpful hairpins that I uncovered in the patient’s medical notes. Five years earlier, her son was killed in a motor cycle accident and her husband ran off with his best, male friend.

Hung-out-to-dry, her subsequent mental breakdown coincided with her BPE record of 333/333. Similarly, at the time when she complained of menopausal symptoms to her GP, her BPE was charted at 334/324 and the apparent deterioration of her periodontal condition recorded. She explained to me that her life had been a bit of a roller coaster, but had improved with the support of her new partner for the previous two or three years.

Neither her dentists, the advising expert nor the GDC were aware of these factors that, together, explained the deterioration recorded by her dentist.  Worse, still, when I examined the patient she was covered in plaque, despite being well informed of her periodontal status. In my opinion, in all probably she would have continued to ignore the advice provided by her new dentist, even if she had been similarly informed by her old dentist.

Did not finish

When legal counsel read my report their reaction was abrupt, to say the least. They demanded I remove all references to her medical records, even after I explained I had a duty to report on all documentation that they had provided. They stated that I was not in a position to contradict the findings of the GDC and their expert, that I was a specialist in periodontics and not an expert in general medical conditions that could affect periodontal health. Finally, they said that I could not possibly contradict the recommendations of the British Society of Periodontology.

I stayed my course, the case was abandoned and the race was over without the claimant even finishing.